Groupwork and assessment. An Overview of Ethical and Practice Issues in Training

by Susan Lindsay

Glossary of Terms

Group psychotherapy/therapy (In accreditation criteria accruing from the beginning of IAHIP c.1990) meant any kind of group work involving personal process which might or might not be assessed.

Group psychotherapy (As decided at an I.A.H.I.P. open meeting, Jury’s Hotel, Dublin c. 2000)  A psychotherapy training group in which assessment cannot take place.

Group work A catch-all term used to describe groups where process work takes place and/or other work which might include skills training. These can be assessed. It could also include group psychotherapy which cannot be assessed.

‘Training group psychotherapy’ A term created by those arguing that there could be a special form of group psychotherapy or group work specifically for trainees which could challenge students to go beyond what happens in ordinary group psychotherapy and take on being assessed as part of the group psychotherapy process.

Therapy Psychotherapy

Introduction

Should group psychotherapy or group work be assessed on training courses? If so, is it still group therapy?  If not, should group therapy be an alternative and distinct requirement.  What are the training issues and ethics involved? What is their relevance for our understanding of Humanistic and Integrative psychotherapy today and who we are as members of the Irish Association of Humanistic and Integrative Psychotherapy? I do not have a partisan position. However this article attempts to describe so the arguments as I understand them and name why this is an important debate for training standards and ethics. I think it’s a great issue to be debating precisely because the arguments go to the heart of the work that defines who we are.

Group work and humanistic psychotherapy

Early influences on the formation of group Humanistic psychotherapy include Fritz Perls, the analyst who developed Gestalt Therapy and Carl Rogers, famous for the communications research undertaken in his pioneering Person Centred encounter groups (Lieberman, Yalom and Miles, 1973). Gestalt therapy emphasises awareness and the importance of working with the immediate moment and its truth. It also emphasises the importance of experience and raising awareness of understanding responsibility issues for Humanistic and Integrative Psychotherapy. Rogers’ research contributed basic data about conditions  under which the most effective therapy takes place, namely attentive listening; empathy, unconditional positive regard and congruence (Yalom,1985).

Underlying values, ethics and philosophy

Our fundamental duty to our clients is to do no harm. Honesty, congruence and awareness are perhaps the first safeguards against doing harm. In conjunction with Maslows’ notion of authenticity, it could be argued that central to any notion of therapy is the understanding that ultimately it is only truth that sets us free. Freedom and authenticity is a desired aim of Humanistic psychotherapy. It holds the ambiguity between the apparently contradictory aims of peak human experience and potential and the existential position of the death of illusion, facing into the void of nothingness. The radical perspective of Humanistic psychotherapy emphasises the clients’ experience. Its philosophy encourages clients to neither rebel nor accept wholesale what society offers as the norm, but to find their own truth and contribute to the ongoing development of society.

History of I.A.H.I.P accreditation and group work

Because so much of humanistic psychotherapy was developed in groups, and group work is so much part of the ethos of this modality, the founding members of I.A.H.I.P. decided that to be accredited, members must have undertaken a minimum of sixty hours of group therapy and an equal minimum number of hours of individual therapy.  The issue of individual therapy hours posed problems for some intending members who worked exclusively with groups. The requirement for group work was a problem for some individual therapists. But the membership felt strongly enough to hold firm. It was agreed that people should be accredited to practise with the clientele appropriate to their training and expertise. Remember at that time, everyone being accredited was being grandparented and that their trainings would have consisted of a variety of very diverse experiences.

At that time, the issue of what constituted group therapy was not raised. However, participation in some kind of humanistic group therapeutic process for at least sixty hours could be assumed to have happened for practically everyone.  It might have included a full range of possibilities; workshop group participation, intensive ten-day group work, or weekly group therapy over months or years. At that time, it was important to have an absolute bottom line minimum as a boundary and to be as inclusive as possible. In fact most people far exceeded the standards set because of their years of experience with ad hoc training which might, or not, have included one particular substantive training.

Assessment as part of group psychotherapy

The current issues about group psychotherapy and group work derive from an intense and heated debate during the development of the Training Standards and Ethics documents. The concern is whether participation in group psychotherapy should be, or even can be, assessed, or whether it can be considered group psychotherapy if assessment intrudes.

At the conclusion of the debate, the decision was that assessment should not be part of group psychotherapy.  I believe a very fair, inclusive, intensive and interesting debate took place and that, in the interests of democracy, the decision taken should be honoured.  In fact it was one of the most satisfying and substantive debates we’ve held in I.A.H.I.P. However, it should be acknowledged many people named their difficulty in fully understanding the issues involved.

At an open meeting in Jury’s Hotel in Ballsbridge, c.2000, a representative group of I.A.H.I.P. members including people at all stages of therapeutic development, from trainees to experienced trainers, debated the issues in depth. Out of the debate, a decision was reached. It was agreed that when assessment enters into a therapy group it should no longer be described as a psychotherapy group.  A psychotherapy group should provide a neutral and confidential space. As it is a great risk to reveal and explore oneself in group, the notion that ones’ participation would be assessed in any way is seen as antithetical to any such process. Group therapy provides a space and a process whereby the way power is given away and projected onto transferential authority figures can be experienced. In a group, the protection, or illusion of protection, that projection offers can be explored. The way projection informs, embodies and preserves social norms and the way it may seem to control and oppress can be explored.  The therapist is the most likely candidate for group projections as she is the one who often holds the most power in the group. Add to this the critical transference issues – particularly relating to family, nurturance and authority – and the assessment and accreditation issues and we can immediately see how complicated things become.

As well as the possible dangers inherent in this situation for the participants, it is a lot for a therapist to hold with clarity.  Crucial is the ability to distinguish between the inherent therapy issues for the participant who, whatever their issues is still okay as person, and the trainee assessment issues. The latter may raise questions as to the trainees’ readiness, or even rightness, to graduate as a therapist.  Where this distinction is not held it can be somewhat disastrous.

During the debate, whilst agreeing that these are critical issues it was suggested that a ‘training group psychotherapy’ could and should be different. Perhaps a training group psychotherapy should include the challenge to address the complications outlined above. This counter position holds that the challenge of working towards resolving or coming to grips with the transference can be highlighted and further augmented by the engaging with the assessment issues.  This happens by bringing the issues out into the open and by insisting that people give their own self-assessment. Furthermore, exchanging feedback with other participants and trainers allows trainees to confront and engage both with the immediate power issues and with the transference issues. Thus they have more possibility of receiving assistance in working towards the resolution of such issues.  It was felt that such an extra challenge can and perhaps, ought to be given to students who need to go further and deeper than non-trainee group participants, if they are to be effective therapists. Those experienced in working in this way described how such a challenge can enrich and move a training psychotherapy group forward. People at the Jury’s meeting, and the guidelines since, decided that this was not the way to go. Students could and perhaps should be involved in group work that can be assessed but it should not be called group psychotherapy.

Central to the debate is an understanding of how transference in addressed in humanistic therapy groups, particularly as it may not even be named as such.  My understanding is that transference is addressed in here and now interactions and through engagement with projections. It is also addressed by looking at the way power is held or given away. At the same time, the therapist remains sensitive to how powerful the deeper transferences held in the group may be. It is also, of course, addressed in the way the group brings family related issues and previous life experiences to the foreground of attention.  Effective group work approaches seem to depend more on the depth of experience of both participants and leaders in relation to the amount of work already done and the difficulties people bring in the first place than on particular approaches or modalities. But there are clear differences of approach between psychoanalytical and humanistic group psychotherapy.

Other possibilities with attendant ethical concerns

In a worst case scenario, participants are in what is called group psychotherapy where no assessment is supposed to be taking place. However the therapist does in fact give feedback to the training team which in turn has impact on the students’ final assessment especially where there may be concern about a student. This is clearly unethical.

More usual is the situation where agreement in contracted clearly with the group from the outset and the therapist tells participants openly anything that will be passed on. However, it has to be recognised that an assessment is taking place however much it may be in the background, and tendencies toward denial of the implications need to be addressed.

An ethical issue can also arise for a group psychotherapist facilitating students who becomes seriously concerned about the probability that a particular participant is going to graduate whilst clearly unsuitable.  With no agreement for assessment included in the contract it seems that her hands are tied and she has to leave assessment to the trainers outside the therapy group.  Maybe this is what should happen, but it is a difficult situation to hold with any degree of comfort and may leave therapists open to future accusations of closed-shop secrecy and collusion about unsuitable therapists being accredited. It can become even more difficult where other student participants in the group are clearly disquieted. They may have no place to go with their concerns due to group confidentiality. This raises the question as to whether students should do their group therapy outside their training centres, in mixed groups not totally comprised of trainees.  But would such humanistic groups be available and if not, does the whole modality and learning experience about what it is to be a Humanistic and Integrative therapist, begin to unravel? Clearly there are no easy answers and there are advantages and disadvantages to different perspectives.

Holding of ambiguity – the present situation

In practice, we seem to have developed a typical Irish solution or, a multi-faceted solution creatively holding what may be a necessary ambiguity. If you want group psychotherapy without assessment, call it such and do not include assessment.  If you want to have assessed group interactive process or assessed personal process, call it for instance, group training/work/workshops and assess participation.

Currently training courses find ways to continue doing things the way they like to do them under the umbrella term of group work and ‘group psychotherapy’ is preserved as a pure term defining a certain kind of group psychotherapeutic experience. The advantage of this shifting of the goalposts is that it allows for diversity whilst its shadow may be the avoidance of conflict which a further debate might bring. The thought occurs; that maybe the ‘Irish solution’ becomes multi-faceted and creative according to the degree of consciousness with which it is used. So the important thing here might be to name clearly what is being done so that arising issues can be addressed in a clear context.

The current dilemma

The current dilemma arises because group psychotherapy has come to mean two different things. There is a requirement for accredited members to have been in ‘group psychotherapy’ and whilst, historically, this may have been acquired in any variety of experience, group psychotherapy has now been redefined (2000). Questions arise about whether students should have to undertake group psychotherapy as newly clarified or whether the old varieties could still be acceptable, either to meet this requirement or in addition to it?

Should training courses require students to experience both kinds of group therapy?  Should the group therapy requirement be modified to allow for the variety of experiences as heretofore? Should assessed group work of any kind be outlawed, as it must inevitably involve transference issues? In this case, how do training schools make any accurate assessment of the students’ ability to engage interactively in a group process? If they cannot, does this matter? If assessment does take place in a therapeutic/process group, regardless of what it is called, how can we be sure trainers are sufficiently experienced as group facilitators? Can we be certain about their ability to be sensitive to and hold the complex issues? Finally, when assessment occurs outside the group, for example in examinations, interviews or in skills observation, how is transference taken into account? Should it be?

Conclusion

These decisions face us as Humanistic and Integrative therapists. They raise major questions about how we engage with transference and what we want to model about transference to trainees. Crucially, it raises questions about identity.  Who are we as Humanistic practitioners when it comes to group work in general? What are the critical factors both ethically and for good practice? What depth do we want students to confront in themselves before becoming therapists? What demands and constraints do we want to put on trainers? And ultimately, what is central and what is peripheral to the learning about a Humanistic and Integrative approach? There are implications for the varieties of training experience currently available. It would seem a pity to restrict the possibilities too greatly except where the practice or training could be described as seriously flawed or could be held to be unethical.

One option might be to require a written rationale from training bodies for whatever practice is taking place. Furthermore, courses and trainers could be held accountable for applying their own policy with integrity. Presumably this could form part of any solution. Too much rigidity is antithetical to a humanistic position or to any depth-psychotherapy approach. Too much laxity gives no way of holding trainers accountable.  Maybe it is desirable to retain the existing broad framework but for learning opportunities to be optimised it is probably necessary that intentions and rationales be stated clearly.

Susan Lindsay is a psychotherapist, supervisor and trainer practising in Dublin and Galway. She was a founder member of I.A.H.I.P. and has enjoyed facilitating groups for over twenty years.

References

Rogers, C.R. (1970) Carl Rogers on Encounter Groups. New York: Harper and Row.

Lieberman, M., Yalom, I.D., and Miles, M. (1973) Encounter Groups: First Facts. New York: Basic Books.

Yalom, I.D. (1985) 3rd Ed, The Theory and Practice of Group Psychotherapy. USA: Basic Books.